This is a proposal for a Mentored Patient-Oriented Research Career Development Award (K23) for Alexia Torke. Dr. Torke began her medical career as a clinician educator in general internal medicine with a focus on medical ethics. After five years as a faculty member at Emory University, she went back into training to complete a fellowship in ethics and primary care. She is currently an Assistant Professor of Medicine at Indiana University and a Research Scientist at the Indiana University Center for Aging Research. Her research now focuses on both medical and ethical aspects of decision making for older adults. Dr. Torke's long term goalis to improve the medical care ofhospitalized older adults who are unable to make their own decisions. This Career Development Award would provide her with the training and protected time needed to accomplish a crucial step toward that goal: characterizing the decision making process as it occurs for these patients. Dr. Torke proposes to conduct a prospective, observational study of older adults and their surrogate decision makers. The specific aims ofthis study are to describe the frequency, characteristics, and clinical context of surrogate decisions, and to identify important determinants of successful communication and high quality decision making from the surrogate's perspective. Patients 65 and older will be identified on admission and followed during their hospital stay. Data will be collected from treating physicians, from medical record review and from in-depth interviews with surrogate decision makers. These results will serve as the basis for future interventions to improve the care of older adults who are unable to make their own medical decisions. Dr. Torke has also designed an educational plan that will further her development as an independent investigator. The plan focuses on four areas that Dr. Torke and her mentors have identified as crucial to her career development: aging and clinical geriatrics; communication theory; grant writing; and clinical trial design. Dr. Torke will attend relevant national conferences and complete formal course work related to each ofthese four areas. She will also expand her knowledge of clinical geriatrics by participating in the Acute Care for the Elders Unit and the memory care practice located within Indiana University. RELEVANCE (See Instructions): As the population ages, the number of patients who face serious illness but are unable to make their own medical decisions will rise. Care at the end of life Is often inconsistent with what patients or families want, and laws that guide surrogate decision making may be out of step with clinical practice. In spite of this, very little research is available that explores the process of decision making as it occurs in the clinical setting.